Transcript Slide 1

Stop Smoking for Safer Surgery
Dr John Oyston
SUMMARY
• People still smoke.
• Smoking is the #1 cause
of preventable deaths in
Canada.
• Perioperative smoking is
bad.
• Perioperative smoking
cessation is good.
• Anesthesiologists should
promote perioperative
smoking cessation.
How bad is smoking?
• 18% of Canadians still smoke.
• The average smoker loses 8
years of life.
• In Ontario, smoking costs us
$1.7 billion in healthcare costs
and $2.6 b in lost productivity
and uses up 500,000 hospital
days.
• One out of every two smokers
will die of smoking-related
diseases.
45,000 smoking deaths versus:
• SARS - 44 deaths
• H1N1
– 78 deaths (so far)
• West Nile Virus
– 10 deaths in bad year
• Homicide
– 561 deaths/yr
• AIDS
– 1,325 deaths/yr
So smoking is a big
Public Health problem.
Why should I care?
Risks of Perioperative Smoking
Risks of Perioperative Smoking
•
•
•
•
•
Cardiac
Respiratory
Wound infections
Wound healing
Disease
recurrence
CARDIAC RISK FROM SMOKING
Woehlck HJ et al, Anes and Analg 1999;89:856
Carbon monoxide a “quick fix”
• The half life of carbon
monoxide is four hours.
• Not smoking for four
hours before surgery cuts
the level one half
• Not smoking for eight
hours before surgery cuts
the level by ¾.
Cut out smoking
before surgery !
Woehlck HJ et al, Anes and Analg 1999;89:856
Cardiac benefits of quitting
• Studies of preop quitting are too small to
have significant result:
– E.g. Smokers 10% Postop cardiac events,
Quitters 0% p<0.08
• Stopping smoking decreases overall
mortality in CAD patients by one third.
• Postoperative quitting reduces long-term
mortality after CABPG.
Post-operative Pulmonary
Complications (PPCs)
• PPCs are much more common in
smokers.
• Takes weeks/months to get benefits of
stopping smoking.
Duration of Cessation and
Risk of PPCs
• 8 wks reduces PPC risk from 48% to 17%
– Compared to 11% in non-smokers
• 4 wks reduces PPC risk to 1.03x nonsmokers
– Continuing to smoke -> 2.09x non-smoker
• 2 wks abstinence -> risk is1.9x that of a
non-smoker
– Continuing to smoke -> risk 4.2x non-smoker
Wound Infections
• Six times more
common in smokers.
• Smokers 12%.
• Non-smokers 2%
(p<0.05).
• 4 weeks of nonsmoking equivalent to
never smoking.
RCT by Sorensen, Annals of Surgery, Vol 238 July 2003: 1-5
Wound Healing
• Delayed in smokers:
– Back fusion.
– Vascular grafts.
• Worse long term outcome of ACL repair.
– 5 years after surgery, smokers had
significantly worse overall knee function, and
more severe pain, more often, than matched
non-smokers (Karim,A JBJS 2006;8-B:1027).
Disease Recurrence
• Peripheral vascular or
cardiac vessel
disease will continue
to get worse if patient
continues to smoke.
• Is it an ethical use of
scarce health care
resources to reoperate on smokers?
Anesthesiologists should
encourage our patients to
stop smoking because:
• It is good for our patients.
• It is good for our hospitals.
• It is good for the healthcare
system.
• It is good for us as a profession.
How?
Inform Patients:
Ask, Advise, Refer
• Ask – “How much do you smoke?”
• Advise – “Smoking increases the risk of
surgery.”
• Refer – “Call this number for help quitting.”
Quit Card
Available by emailing from the Johnson and Johnson booth
or by emailing John Oyston at [email protected]
www.StopSmokingForSaferSurgery.ca
Smokers’ Helpline:
Help by phone, web and email
What else can we do?
• Inform the public
– Interviews on CBC
Radio and TV
– Global and CTV
– Toronto Sun
– Metro
– Globe and Mail
Inform colleagues and
administrators: OA Action Plan
i)
ii)
iii)
iv)
Identify smokers preoperatively.
Explain that smoking increases the risk of surgery.
Refer smokers to smoking cessation services.
Consider delaying surgery in patients who have
smoked recently.
v) Follow up on smokers to encourage them to continue
not smoking after surgery.
vi) Encourage non-smoking hospitals.
No Smoking at TSH
Feb 1st 2010
• No smoking
anywhere on hospital
property
• Staff education and
help quitting
• Preoperative teaching
for elective patients
• NRT available on
formulary
Ongoing Policy Development
• Patient handout being developed.
• Working with CAS to develop national
strategy.
• Working with Accreditation to make
Perioperative Smoking Cessation support
a required organizational practice.
Please – do your part!
• Ask, Advise, and Refer.
• What else can you do in the Preadmission
Clinic which will:
– Reduce perioperative complications
(52% ->18%).
– Improve wound healing and decrease wound
infection rate (six fold).
– Save your patient’s life!
Thank You
Questions?
Email:
[email protected]
StopSmokingForSaferSurgery.ca
Additional Info
Does cessation immediately before
surgery increase pulmonary risk?
• Clinical impression only…
• Some studies have higher rate of PPCs in
pts who quit shortly before surgery.
• NOT statistically significant.
• NOT randomised.
• “The evidence suggesting an increased risk during the
first weeks of quitting is insufficient to support any
recommendation that smokers do not strive for
preoperative abstinence” - Warner
Is perioperative NRT safe?
• YES
– NRT does not produce adverse cardiac
effects in volunteers or smokers
– NRT reduces exercise-induced ischaemia
– NRT does not affect patency of CABG grafts
– NRT is safe in patients with cardiovascular
disease
– But NRT may exaggerate cardiovascular
response to intubation